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A New Look at Cellulite, Part II

By: Peter T. Pugliese, MD
Posted: July 23, 2008, from the August 2008 issue of Skin Inc. magazine.
Woman doing yoga with apple in foreground


Part one of this two-part series, which ran in the July 2008 issue, discussed the causes of cellulite. Part two will take a look at the pathological changes in cellulite tissues, as well as a new treatment for cellulite.

Pathological changes in cellulite tissues

The first step in the genesis of cellulite is the initial breakdown of the collagen fibers that form the separation between the fatty compartments, called trabeculae. This process occurs during many years and is continuous. It starts at the same time that menses starts—menarche. Each month, a further MMP insult is sent out from the uterus to all parts of the body, wreaking havoc in the connective tissue. Just how estrogen ties in to this process, science does not know for certain, except that there is an inseparable relation between estrogen and MMPs. One thing that is known is that when the MMP destruction surges each month, there is no repair crew coming to set the tissue right again and clean up the mess wrought by the MMPs.

The second step is the release of fatty tissue, which was confined to the tight, though flexible, compartments. This fat now escapes and moves both upward and laterally through a maze of broken and tangled fibrous bands. Some bands are still tied to the muscle layer and connect to the bottom of the dermis, restraining the movement in certain areas of the thighs and buttocks. This is the cause of the undulating surface of the skin appearance of cellulite. It does not have an orange-peel appearance as has been described in the literature unless tightly compressed by hand.h At times the fat has been known to become painful, which has led some investigators to think this a panniculitis, or even a lipodystrophy of some type.i There may be some inflammatory component present when considering the degree of tissue destruction in the cellulite-involved area. All this tissue damage, all the MMPs and all the cytokines must leave a host of peptides and small cellular entities that are potentially antigenic.

The third and final destructive step is the continued cycling of the MMPs, and the return of the destruction of connective tissue. The body has only one month to get ready for another onslaught and another wave of havoc. This process will continue until menopause, but another culprit prepares to take the place of the menstrual cycle. During the child-bearing years, women gradually lose their production of collagen from the fibroblasts, and the secretion of MMPs increases to continue to break down the collagen, not only in the cellulite areas, but also just about everywhere there is connective tissue. At this time, the ovaries start to shut down and make less estrogen, but the adipose tissue takes up the slack. Women who are overweight—50 pounds or more, perhaps less—will continue to make estrogen via the adipocytes. The more adipocytes, the more estrogen is produced. So the estrogen and MMPs go on their merry way, leaving shattered lives in their wake, and there is little that can stop them—but they can be stopped.

A new treatment for cellulite

Following are specific treatment instructions for cellulite, and although it may not be the final word on cellulite, it is the best information that is currently available.